-
incising tissue:
- Scalpel
- Most common use: #3 handle (more slender, longer #7 is used sometimes) with #15 blade (for incision
- around teeth and through mucoperiosteum)
- Blade inserted with needle holder no laceration
- Pen grasp onto the scalpel maximal control!
- Dull edge → no clean sharp incision but tears the tissue!!!
-
2. Instruments for elevating mucoperiosteum:
- periosteal elevator
- Reflect mucosa and periosteum in a single layer!
- Most common: #9 Molt periosteal elevator!
- (i) Sharp, pointed end: reflect dental papillae from teeth
- (ii) Broad end: elevating tissue from bone
- 3 methods of reflecting soft tissue
- (i) Pointed end used to pry elevate soft tissue → for dental papilla from inbetween teeth
- (ii) Push stroke with broad end from underneath the periosteum → MOST efficient stroke/cleanest reflection
- (iii) Pull/scrape stroke → shred or tear the periosteum unless done carefully
-
Instruments for retracting soft tissue
- a. Cheek retractor:
- NOTE: 1 & 2 retract both cheek and mucoperiosteal flap
- 1) Right-angle Austin retractor
- 2) Offset broader Minnesota retractor
- 3) Seldin retractor: only soft tissue flap but not mucoperiosteum (bc not sharp)
- b. Tongue retractor
- 1) Most common: Mouth mirror
- 2) Weider tongue retractor: more firmly engage tongue and retract more anteriorly and medially
- Careful not to push tongue too far back and cause gagging reflex!
- 3) Towel clip (especially for biopsy of posterior aspect of tongue!) → must be anesthesized!!!
-
Instruments for controlling hemorrhage
- → for simple pressure control: Hemostat!
- Most common: curved hemostat!
- Locking mechanism allows to clamp to vessel
- Also used for: removing granulation tissue from tooth sucket, picking up small root tips, calculus, amalgam
- restorations…
-
Instruments for grasping tissue:
- a. Adson forceps to stabilize soft tissue flaps to pass a suture needle!
- b. Stillies forceps: for posterior part of the mouth!
- c. Sometimes cotton forceps if needs to be angled!
- d. Allis tissue forceps: when need locking handles and with teeth grips
- NEVER to be used for tissue that will stay in the mouth since this will destroy the tissue by crushing it!
- e. Russian forceps: for grasping teeth that are loose in the mouth!
-
6. Instruments for removing bone
- a. Roungeur Forceps
- Most commonly used to remove bone!
- With spring-loaded handle repeated cuts of bone without manually opening the instrument
- 2 Types: side cutting or end cutting or Blumenthal roungeur (side and end cutting)
- smaller amounts of bone in multiple times
- do not remove teeth with Roungeur forceps
- b. Chisel and Mallet
- Bone with monobevel and teeth with bibevel chisels
- Mallet with nylon facing impart to ↓ noise
- c. Bone File
- Final smoothing of bone before suturing the mucoperiosteal flap back into position
- File only on pull stroke!
- d. Bur and Handpiece
- MOST used by surgeons to remove bone or teeth!
- 2
- Must not exhaust air into operative field as do dental drills!!! → bc air may be forced into deeper tissue
- planes and produce tissue emphysema (potentially dangerous occurance!)
-
Instruments for removing soft tissue from bony defects:
- periapical curette!
- To remove granuloma or small cysts from periapical lesions or tooth sucket!
-
Instruments for suturing mucosa
- a. Needle holder (locking handle and a short, stout beak)
- Beak is shorter and stronger than that of hemostat
- Face of beak is crosshatched positive grasp of the suture needle and suture!
- Intraoral placement of suture → 6 in needle holder!
- Held by using thumb and ring finger in rings and first and 2nd fingers to control instrument!
- b. Needle
- For mucosal suture: ½ or 3/8 circle suture needle! → allow the needle to pass through a limited space
- Tapered tip or triangular tips (cutting tips easily pass mucoperiosteum!)
- Suture can be either threaded or already swaged by manufacturer
- Curved need held about 2/3 distance between tip and end of needle!
- c. Suture Material (dpend on size, resorbability and monofilament vs polyfilament)
- Oral mucosa: commonly 3-0 (or 000)
- (i) Larger size suture would be 2-0 or 0
- (ii) Smaller size: 4-0, 5-0, 6-0 → maybe in face bc smaller suture cause less scarring
- 3-0:
- (i) large enough to prevent tearing through mucosa
- (ii) strong enough to withstand tension intraorally
- (iii) strong enough for easy knot tying with needle holder
- Resorbable vs. non-resorbable
- (i) Non: silk, nylon, stainless steel
- (ii) Resorbable 1° made of gut!
- a) aka: catgut but mainly sheep intestine → lasts about 5 days
- b) chromic gut lasts 10-12 days bc treated with tanning solution (chromic acid)
- NOTE: some are synthetically made resorbable!!! : long chains of polymers braided into suture material
- → lasts about 4 weeks! not indicated in oral cavity!
- Example: polyglycolic acid and polylactic acid!
- Monofilament vs polyfilament
- (i) Monofilament: plain, chromic gut, nylon and stainless steel
- a) No wicking action
- b) More difficult to tie, tend to become untied
- c) Stiffer more irritating to soft tissue
- (ii) Polyfilament: skilk, polyglycolic acid, polylactic acid
- a) Easier to handle and tie and rarely come untied
- b) Cut ends are soft and nonirritating to tongue
- c) “wick” oral fluids along the suture to tissues which may carry bacteria along with saliva!!!
- NOTE: MOST COMMON USED IN ORAL CAVITY IS 3-0 black silk!!!
- Strong enough
- Easily tie and tolerated by pt
- Black makes it easy to see for suture removal
- Since suture no longer than 5-7 days, wicking action is of little clinical importance!
- d. Scissors: to cut sutures!
- Most common: Dean scissors!: slightly curved handles and serrated blades
- Others: Iris and Metzenbaum scissors
-
Instruments for holding mouth open:
- especially for mandibular extractions, must prevent stress on TMJ
- a. Bite block: rubber block that pt rests their teeth
- If must open wider, bite block positioned more posteriorly
- b. Side-action mouth prop or Molt mouth prop→ used by operator to open mouth wider if necessary!
- Caution since ↑ pressure on teeth and TMJ
- Only for pts that are deeply sedated
- NOTE: always caution not to open too widely bc stress on TMJ and if it’s a long surgery, periodically remove and allow TMJ
- to relax!
-
Instruments for providing suction: for adequate visualization
- a. Surgical suction: smaller orifice than operative suction for tooth socket!
- 3
- b. Fraser suction : holde in the handle portion that can be covered as required
- 1) Hard tissue suction: hole is covered under copious irrigation
- 2) Soft tissue: uncovered to prevent tissue injury
-
Instruments for transferring sterile instruments:
- Transfer forceps
- Can move large and small items without dropping them
- Stored in container filled with bactericidal solution (glutaraldehyde)
- Must be emptied and replaced at least every other day and autoclaved at least once per week
-
Instruments for holding towels and drapes in position:
- Towel clip
- Locking handle & finger and thumb rings
- Ends: sharp, curbed points penetrate towel and drapes
- Caution not to pinch the pt’s underlying skin
-
Instruments for irrigation:
- large plastic syringe with blunt 18-gouge needle (blunted and smoothed and angled!!)
- NOTE: when handpiece and bur is used to remove bone, need steady stream of irrigating solution: usually sterile saline
- to cool bur and prevent bone-damaging heat buildup!
- ↑efficiency of bur by washing away bone chips from flutes of bur and for lubrication
-
Dental elevators:
- to luxate teeth (loose them) from surrounding bone
- minimize incidence of broken roots and teeth
- facilitate removal of broken root later if it happens
- expand alveolar bone
- also used to remove broken or surgically sectioned roots from sockets (especially roots!!!)
- a. Components
- 1) Handle
- Large substantial but controlled force
- May use with crossbar or T-bar → careful bc ↑↑amount of force is generated!
- 2) Shank: connects handle to blade
- 3) Blade: working tip that is used to transmit for to tooth, bone or both
- b. Types (biggest variateion: shape and size of blade)
- 1) Straight or gouge type: luxate teeth (MOST COMMONLY USED)
- Concave on one side used like shosehorn
- Blade: can be angled from shank allow use in posterior region of mouth (ex: Miller and Potts elevator)
- 2) Triangle or pennant-shape type: when broken root remains in tooth and adjacent socket is empty
- Provided in pairs (left and right) for specific roots
- Most common: Cryer
- 3) Pick type: to remove roots
- Crane pick: heavy instrument for removing root after drilling a hole with a bur (3mm into root)
- Root tip pick/ apex elevator: small root tip fragments from their socket (VERY THIN instrument must
- tease not lever!)
-
Extraction Forceps: remove tooth from alveolar bone
- a. Components
- 1) Handle: adequate size enough pressure and leverage to remove required tooth + serrated surface no slippage
- Held differently depending on position of tooth to be removed
- (i) Maxillary: palm underneath forceps
- (ii) Mandibular: palm on top of forceps beak down
- 2) Hinge: connects handle to beak
- Transfers and concentrates force applied to handles to beak
- Types
- (i) American type: hinge in horizontal direction
- (ii) English: vertical hinge vertically positioned handle
- 3) Beaks: greatest variations
- Adapts to tooth ROOT STRUCTURE at the CEJ different beaks for 1,2, 3 rooted teeth chance of
- root fracture!
- Closer beak adapts to tooth roots, more efficient extraction and less chance for complications
- Width of beak depending on type of teeth removing
- Beaks are angles parallel to long axis of tooth
- (i) Maxillary beak: usually parallel to the handle (offset a little for comfort)
- (ii) Mandibular beak: usually perpendicular to handles
- b. Maxillary forceps
- 4) Considered single rooted teeth: Maxillary incisors, canine, premolar (even though 1PM bifurcates since only care
- about root near CEJ)
- Remove with maxillary universal forceps (usually #150 for anterior and #150A for premolars)
- NOTE: #150S (smaller version) for all primary maxillary teeth!!!
- Straight forceps #1 is easier for maxillary incisors
- 2) Considered 3 roots for maxillary molars (1 palatal root and buccal bifurcation)
- Molar forceps in pairs: Right and Left
- (i) #53: Design to fit around palatal beak, pointed buccal beak into buccal bifurcation and offset for good
- positioning
- (ii) #88 (a.k.a.; upper cowhorn forceps): longer, more accentuated, pointed beak formation
- NOTE: ESPECIALLY USUFUL FOR MAXILLARY MOLARS WITH DECAYED CROWNS, BUT MAY
- CRUSH ALVEOLAR BONE
- (iii) when have single conical root for some reason: #210: broad, smooth beak with offset
- (iv) Removing broken roots/ narrow premolars/lower incisor: #286 (a.k.a.: root tip forceps)
- c. Mandibular forceps
- 1) Considered single rooted teeth: Anteriors and premolars
- Lower universal forceps: #151 (similar to 150 but beak pointed inferiorly) for anteriors and #151A for PM
- English-style vertical hinge forceps sometimes for mandibular single rooted teeth force generation
- fracture rate
- 2) 2-rooted teeth for molars: B and L bifurcation
- ONLY single molar forceps (no R and L)
- Mostly #17: straight handled and oblique beaks and bilateral pointed tips for bifurcations
- #222 for conically shaped roots of mandibular molars (no bifurcation 3rd molar) since no pointed tips
- #23 (a.k.a.: cowhorn forceps): two pointed heavy beaks that uses B/L cortical plates as fulcrum risk of
- fracture of alveolar bone
- #151S for all mandibular primary teeth
-
Typical extraction pack with (required forceps lateral added)
- 1. Local anesthesia syringe
- 2. Needle
- 3. Local anesthesia cartridge
- 4. Woodson elevator
- 5. Periapical curette
- 6. S/L straight elevator
- 7. Cotton pliers
- 8. Curved hemostat
- 9. Towel clip
- 10. Austin retractor
- 11. Suction
- 12. Gauze
-
Surgical Extraction tray
- : for incision, reflection of soft tissue, removal of bone, section of teeth, retrieval of roots, debridement and suturing
- 1. basic
- 2. needle holder
- 3. suture
- 4. scissors
- 5. periosteal elevator
- 6. blade handle
- 7. blade
- 8. Adson tissue forceps
- 9. bone file
- 10. tongue retractor
- 11. root tip pick
- 12. Russian tissue forceps
- 13. Cryer elevator
- 14. Roungeur
- 15. handpiece and bur
-
Biopsy tray: for incision and dissection and closure of wound
- 1. Basic
- 2. Blade handle and blade
- 3. Needle holder and suture, suture scissors
- 4. Metzenbaum scissors
- 5. Allis tissue forceps
- 6. Adson tissue forceps
- 7. Curved hemostat
-
Postoperative tray: to irrigate surgical site and remove sutures
- 1. Scissors
- 2. College pliers
- 3. Irrigation syringe
- 4. Applicator sticks
- 5. Gauze
- 6. Suction
-
Maxillary forceps
- 150: anterior
- 150A: premolars
- 150S: primary
- #1 forceps: primary incisors
- 53: 3 root molars
- 88: cowhorn, molars
- 210: molars single conical root
- 286: both max/mand broken roots, narrow premolars
-
Mandibular forceps
- 151: anterior
- 151A: premolars
- english, vertical: single rooted
- 17: dobuble rooted
- 222: molars
- 23: cowhorn, molars
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